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DSAEK surgery could be done under retrobulbar block anesthesia, an injection of anesthetic medicine to the back of an eye. General anesthesia is often necessary since it minimizes posterior pressure on the globe and the risk of patient movement during the surgery.
We typically use an eye drop (1% pilocarpine) to constrict the patient’s pupil right before the surgery. However, dilating drops will be used if combined procedures of DSAEK and cataract surgery are performed.
The cataract will have to be removed first with cataract surgery and intraocular lens implant, followed by DSAEK surgery. These two surgeries could be done simultaneously or with a staged approach.
The donor corneal tissue is prepared with a Moria microkeratome and an artificial chamber just prior to the surgery on the patient’s eye. The donor tissue is placed onto an artificial chamber and cut with a microkeratome to a depth of 300-350 microns and 9.5 mm or more in diameter. The cut donor tissue is then punched with a Hana trephine to 9 mm in size for the transplant.
DSAEK surgery is performed with a small incision from the temporal side of the cornea in order to provide the greatest manual access and visualization for the surgeon. Two clear corneal incisions are also placed about 5 clock hours apart to be used as access points to the anterior chamber during the operation.
A reverse Sinskey hook is used for the descemet's stripping portion of the procedure. The diseased endothelium and thickened descemets membrane of the recipient is punctured by the blunt tip of the reverse Sinskey hook. Once descemets membrane has been completely stripped with the hook, the diseased tissue can be removed from the chamber and sent to pathology.The previously-prepared donor tissue is then folded with a pair of special folding forceps and implanted into the anterior chamber of the eye. After manipulations to center the donor tissue inside the eye and to remove the fluid between the donor tissue and the host, the anterior chamber is then completely filled with air to help with the adherence of the donor tissue to the endothelial side of the cornea.
An occlusive patch and shield are routinely placed on your eye after the surgery. The patient is then discharged from the outpatient hospital when fully recovered from anesthesia. The patients are required to lie in a supine position, flat, facing the ceiling, for the first hour after surgery and then as much as reasonably possible to allow the retained air bubble to further stabilize the graft position.
The patient is seen the next morning and the patch is removed. Most patients would not encounter any discomfort that would require any narcotic pain relief. If the donor tissue transplant is dislocated, then the patient will need to be taken back to surgery for the repositioning of donor tissue with more air bubbles.
If the graft is in good position on day one, it will heal in good position. The edges of the graft seal down with solid healing sometime within the first 3 months. The overlying cornea has a variable rate of clearing, but some patients are able to see as well as 20/25 only one week after DSEK surgery with a crystal clear central cornea.
The postoperative medical therapy after DSEK surgery is identical to what is done with conventional corneal transplant surgery patients. Topical steroids (1% prednisolone acetate) is used four times a day for 3 months, then three times a day until 6 months, then twice a day until 9 months, and then once a day until one year postoperatively. The steroids are then tapered down further until discontinued entirely. Topical antibiotic eye drops are used four times a day for the first two weeks after DSAEK surgery and then discontinued.
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Jackson, MS 39216